Question

Patient: B.A.            Age: 57        

Isolation: Contact- MRSA

Allergies: Sulfa

0800 Assessment

HPI

B.A. is a 57 yo male with a history of uncontrolled Diabetes Type 2 diagnosed in 2008. Pt was admitted with c/o increased numbness and tingling, and decreased sensation in his lower extremities x 4days. Pt reports that he noticed a reddened swollen area on his right leg that appears to be spreading.

Physical Examination

BP: 134/86 Lt arm sitting

HR: 96 regular rate and rhythm

R: 18/min

SPO2: 97%

Wt: 160lbs

Ht: 5’5”

Bilateral radial pulses 2+/4, Rt dorsalis pedis pulse 1+/4. The right calf is twice the size of the left one. The skin on the rt calf is erythematous with 2+ pitting edema.

IV Access: 20 gauge Lt AC PIV infusing 0.9 NS @ 100ml/hr. Site has some mild erythema and swelling. Pt has pain 4/10 at IV site

Intake: 50% of breakfast (pancakes and bacon), 200ml of juice

Urine Output: 180ml straw colored urine

Diagnostics

Ultrasound: DVT in rt leg

Develop a nursing diagnosis and plan for a patient using the above information. Write what parts of the information provided go in subjective or objective section.

Answer 1

Patient Name: B.A Age: 57 years

SUBJECTIVE DATA:- 57 Years old male patient came to the hospital with the following complains:

• Patient has history of uncontrolled Type-2 diabetes diagnosed in 2008.
• Patient complains of increased tingling, numbness and decreased sensation in lower extremities since 4 days.
• Patient complains about red and swollen area on right leg that appears to be spreading.

OBJECTIVE DATA:-

• Patient is assessed for sign and symptoms and history is taken.
• Vital signs are assessed and are normal i.e. B.P 134/86 mmhg, H.R= 96 regular rate and rythm, R= 18/min, SpO₂ = 97%, Weight= 160lbs, Height= 5'5". Bilateral radial pulse 2+/4, right dorsalis pedis pulse 1+/4.
• Patient has right calf twice the size of the left calf and skin on right side is erythmatous with + pitting edema.
• Patient has normal intake output i.e. Intake 50% of breakfast and 200ml juice, Output= 180ml straw coloured urine.
• Diagnostic tests are performed and DVT is diagnosed in right leg.

NURSING DIAGNOSIS:

1. Impaired skin integrity and sensation related to disease condition i.e. Deep Vein Thrombosis.

GOAL: To maintain skin integrity and skin sensation of patient.

  PLAN:

• Assess the impaired skin integrity and skin sensation.
• Educate patient to maintain proper hygiene of the area.
• Donot allow the moisture to accumulate on the impaired area.
• Elevate the lower extremities to maintain blood circulation to the area.
• Keep wound clean and dry and if bandage is apply change it daily.
• Assess the area daily to notice if the swelling reduced or not.
• If DVT pump is applied to patient remove it after every hour to maintain blood circulation and to prevent further skin impairment.

2- Acute Pain to the patient at IV site due to cannulization.

  GOAL: To reduce the pain of the patient.

PLAN:-

• Assess the level of pain as it is 4/10.
• Assess for any erythema and swelling.
• Assess if the drip is continuous or change the cannula id drip stops.
• Assess for any sign of infection such as drainage, puss formation etc.
• Provide analgesic if required as ordered by physician.

3- Risk of infection related to wound on right leg.

  GOAL:- To reduce the risk of infection in patient.

  PLAN:-

• Asses the risk of infection in patient.
• Assess the area for any swelling and reddness, i.e patient has right calf swollen twice the size of left side.
• Provide education to patient to maintain proper hygiene.
• Clean the wound daily and change the bandage.
• Ask the physician regarding proper treatment and take antibiotics as prescribed by the physician.
• Take diuretics to reduce water accumulation in body such as edema.